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Examining the Emergency Department Bottleneck

by Rick Blizzard, D.B.A.

Health and Healthcare Editor

In an emergency, there's nothing more frustrating than feeling
you're being put on the back burner. That's why there is a direct
relationship between the amount of time that patients wait for
emergency treatment and their levels of satisfaction with their
experience. Patients who wait for an average of 35 minutes or less
tend to be satisfied, and those who wait for 72 minutes or more
tend to be dissatisfied.

Being seen by a physician at a hospital emergency department is
typically a multi-step process. Patients must be greeted upon
arrival, taken to a treatment room, and be seen by a nurse and a
doctor. Which stage of this process takes the longest, and which
stages are patients most dissatisfied with?

Emergency Department Bottlenecks

To improve wait times and overall patient satisfaction with the
emergency department, we must identify the location of the patient
bottlenecks. While the circumstances are unique for each emergency
department, an examination of results from Gallup's 2002 patient
satisfaction and loyalty database can provide some insight.

Approximately 20% of emergency department patients are
dissatisfied with their wait times. Gallup provided these patients
with a list of points in the emergency department process and asked
them whether they encountered unsatisfactory delays before each
one:

Being greeted by someone in admitting

Being taken into a treatment room

Being treated by a nurse

Being treated by a physician

There is wide variation in patient perceptions of where
bottlenecks occur. Thirty percent of patients who were dissatisfied
with their wait times said there was an unsatisfactory delay before
being greeted in admitting, a relatively low figure compared to the
68% who were dissatisfied with the time it took to be taken to a
treatment room and 65% dissatisfied with the delay before being
treated by a physician. There is significant potential for
improvement at every stage, but the two major bottlenecks are
clearly the latter two phases.

How to Eliminate Bottlenecks

Patients go to emergency departments with urgent health needs
that require a physician's treatment. Yet nearly two-thirds of
patients who are dissatisfied with wait times experienced
unsatisfactory delays before seeing a doctor. Dissatisfaction with
this stage could indicate inefficiency in any or all of the steps
leading up to this important point in the process, but there is
undoubtedly an urgent need for physician-patient contact as early
in the process as possible. Such contact may be occurring too late
if it is always relegated to the final point in the chronological
progression of emergency department treatment.

There are two basic strategies for improving patient
satisfaction with the time it takes to see a physician. The first
strategy is getting the patient to the physician as quickly as
possible. Many hospitals have successfully addressed this issue by
implementing bedside registration. But even this approach will fail
if the patient then faces an extended wait in the treatment room
before being treated by the physician. The question then becomes
not how to get the patient to the physician faster, but how to get
the physician to the patient faster.

What are the possible process implications of that reversal? An
obvious one is to increase the number of physicians in the
emergency department. But given resource constraints, many
facilities will need to think in terms of more effective
utilization of existing physicians. Why not free physicians from
being bounded only to patient contact in the treatment room, and
get them directly involved with the initial triage process in the
front of the department?

Clearly, thought-process barriers exist to such a major reversal
to the treatment paradigm. But perhaps such a major revolution is
necessary to solve the emergency department crisis. This type of
revolution worked with the implementation of bedside registration.
Is earlier physician involvement the next step?

As a senior consultant for Gallup Healthcare, Dr. Blizzard helps to lead Gallup's efforts to measure and serve the healthcare industry. In his 12 years at Gallup, Blizzard has consulted extensively with healthcare organizations about public, patient, physician and employee perceptions and their implications.

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